Autism Spectrum Disorders

by Anne Lambert, MS

Autism is a strongly heritable disorder of the developing brain characterized by significant delays in socialization and communication as well as repetitive patterns of behavior that manifest before three years of age.(1) Evidence also exists for the onset of autistic behavior between 6-12 months in siblings of autistic individuals who themselves go on to develop autism.(2) Autism spectrum disorders (ASD), including Asperger's syndrome, affect about 560,000 Americans under the age of 21, according to the Centers for Disease Control and Prevention. One out of every 150 children will be diagnosed with ASD by the age of 8, which is more than 10 times the reported rate in the 1980s.(3) In community surveys, autism affects as many as 20 children per 10,000, which is considerably higher than the prior estimate of 5 per 10,000.(4) There is some controversy about whether the increasing number of cases is due to an increased number of occurrences, changes to diagnostic standards, or increased screening.(5) Autism spectrum disorders have a lifelong impact on the quality of life for patients and caregivers.

Recognition and diagnosis of autism spectrum disorders has expanded to include sophisticated eye-tracking software used by McMaster and Yale Universities.(5) However, according to Catherine Lord, director of the University of Michigan Autism and Communication Disorders Center, clinician testing definitely adds predictive value. During screening, children are observed completing a set of human- and object-oriented tasks. Typical symptoms of autism include aversion to normal social interaction, delays in language development, repetitive actions and sometimes self-abuse.

Although there is no known medical cure, Geraldine Dawson, chief science officer of advocacy group Autism Speaks says that, "By providing very intensive early intervention we can significantly reduce the symptoms of autism. […] But there is huge variation in how children respond to early intervention."

Studies of preschool-age children with autism have shown that early, intensive behavioral treatment, which can include encouraging children to look at people's faces, express emotions, and try to limit repetitive tics,(5) produces greater gains in language and IQ scores compared with children whose treatment begins later in childhood or adolescence.

However, in a survey conducted by Rhoades and colleagues, it was found that the average age of ASD diagnosis was 4 years, 10 months, which is later than optimal for the most benefit from early intervention.(5, 6) The Rhoades study also found that healthcare providers offered minimal information after diagnosis and that caregivers turned to outside sources for more information.(6) It is important to educate healthcare providers about the pivotal role they play in developing and managing comprehensive treatment plans for each patient.

In an effort to help clinicians provide the best care to their patients with ASD, the American Academy of Pediatrics updated their clinical reports in November 2007. The first report addresses background information, including definition, history, epidemiology, diagnostic criteria, early signs, neuropathology, and etiology. It also provides an algorithm for early identification of children with ASD. The accompanying clinical report addresses the management of children with autism spectrum disorders. A resource toolkit is also available, which contains screening and surveillance tools, practical forms, tables, and parent handouts to assist the pediatrician in the identification, evaluation, and management of autism spectrum disorders in children.(7)

Dr. Michael Aman, Ohio State psychologist and investigator in a study on the cognitive effects of atypical antipsychotics in children with autism,(10) says that “the safety and effectiveness of medication is being analyzed for children with behaviors that can place particular strain on families. Irritability, tantrums and aggression are not universal characteristics, but are ‘reasonably common.’ Many of these kids present families with very serious challenges,” Aman said. A recent survey of children with pervasive developmental disorders found that approximately half are currently being prescribed a psychotropic drug and that 16.5% are taking an atypical antipsychotic drug.(8) Moreover, as patients with autism age, their use of medications increases.(9) There is a need for clinicians to stay abreast of new research on pharmacotherapy that may be effective in the long-term treatment of patients with autism.

The most commonly prescribed classes of psychotropic medications for ASDs include antipsychotics, psychostimulants, anxiolytics and hypnotics, antidepressants, and, to a lesser degree, antihypertensives and mood stabilizers.(2) Currently, the atypical antipsychotic risperidone is the only FDA-approved agent for the treatment of irritability, aggression, self-injury, and tantrums in autistic children and adolescents. Studies investigating aripiprazole,(10) olanzapine, quetiapine, and ziprasidone show that these medications have some efficacy in reducing certain behavioral symptoms, but like risperidone, they can be associated with some adverse effects that may limit use or adherence. Although these agents show promise for the treatment of many ASD symptoms, there is limited availability of controlled data to guide clinical practice.(11) There is a need to continually educate physicians on the necessity of matching different symptom clusters with specific neuropharmacological substrates to dictate rational pharmacotherapy for patients with autism.

Management strategies for treating aggressive behaviors in children with autism depend on behavioral assessment at regular intervals and intervention with pharmacotherapy that can help manage maladaptive and dangerous behaviors. From a pharmacotherapy perspective, atypical antipsychotics have shown the most promise in reducing aggressive behavior. Future directions in treating aggression in children with autism include further investigation of atypical antipsychotics that may not cause significant weight gain and testing the efficacy of manualized behavioral treatments.(12)

Since children and adolescents with ASD clearly benefit from early diagnosis and long-term treatment, there is a real need for healthcare providers to have access to evidence-based therapies and knowledge of new pharmacotherapy options that can be incorporated into long-term management strategies. For more information on autism, visit the National Institute of Mental Health Autistic Spectrum Disorders (Pervasive Development Disorders) website at http://www.nimh.nih.gov/health/publications/autism/complete-publication.shtml. You will find more helpful information on the Autism Society of America website at http://www.autism-society.org.

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References

1. Diagnositic and Statistical Manual of Mental Disorders, TR ed. Washington, DC: American Psychiatric Association; 2000.
2. Leskovec TJ, Rowles BM, Findling RL. Pharmacological treatment options for autism spectrum disorders in children and adolescents. Harv Rev Psychiatry 2008;16:97-112.
3. Autism Information Center. Centers for Disease Control and Prevention;Available at: http://www.cdc.gov/ncbddd/autism/overview.htm.
4. Fombonne E. The prevalence of autism. JAMA 2003;289:87-89.
5. Singer-Vine J. New Ways to Diagnose Autism Earlier. Wall Street Journal. July 8, 2008.
6. Rhoades RA, Scarpa A, Salley B. The importance of physician knowledge of autism spectrum disorder: results of a parent survey. BMC Pediatr 2007;7:37.
7. Johnson CP, Myers SM. Identification and evaluation of children with autism spectrum disorders. Pediatrics 2007;120:1183-1215.
8. Aman MG, Lam KS, Van Bourgondien ME. Medication patterns in patients with autism: temporal, regional, and demographic influences. J Child Adolesc Psychopharmacol 2005;15:116-126.
9. Posey DJ, McDougle CJ. Pharmacotherapeutic management of autism. Expert Opin Pharmacother 2001;2:587-600.
10. Stigler KA, Diener JT, Kohn AE, Erickson CA, Posey DJ, McDougle CJ. Aripiprazole in Asperger’s Disorder and Pervasive Developmental Disorder Not Otherwise Specified: A 14-Week Prospective, Open-Label Study. Paper presented at: American College of Neuropsychopharmacology 46th Annual Meeting; December 9-13, 2007; Boca Raton, FL.
11. McDougle C. Atypical Antipsychotics in Autism Spectrum and Distruptive Behavior Disorders. In: Treatment of Children and Adolescents with Psychiatric Disorders: The Rising Use of Antipsychotics, ISS12. Paper presented at: 161st Annual Meeting of the American Psychiatric Association; May 3-8, 2008; Washington, D.C.
12. Erickson CA, Swiezy NB, Stigler KA, McDougle CJ, Posey DJ. Behavioral and pharmocologic treatment of aggression in children with autism. Psychiatric Times 2005;22: Available at: http://www.psychiatrictimes.com/autism/article/10168/52276.